I understand that I am financially responsible for all charges
whether or not paid by insurance. I hereby authorize High Desert Oral Surgery
and Implant Center, PLC to release all information necessary to secure payment
of benefits and I authorize the use of the signature below on all insurance
submissions.
I assign any insurance benefits directly to High Desert Oral Surgery and
Implant Center, PLC.
THERE ARE FEES ASSOCIATED AND DUE WITH ALL CONSULTATIONS, XRAYS AND TREATMENT.

I certify that I have read and understand the above. I acknowledge that my questions, if any, about the above questions have been answered to my satisfaction. I will not hold Dr. Harris or his staff responsible for any errors or omissions that I have made in the completion of this form. Furthermore, I authorize Dr. Harris to communicate with my other healthcare providers to facilitate the coordination of my care.